A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following is an expected finding?
Stuporous level of consciousness
Seizure activity
Pathological change on CT scan
Bradycardia
The Correct Answer is B
When a client is experiencing alcohol withdrawal, seizures are a common finding. Benzodiazepines are the preferred medications for alcohol withdrawal, and they are used to prevent seizures and treat symptoms of anxiety, agitation, and autonomic hyperactivity. Stuporous level of consciousness (Choice A), pathological changes on a CT scan (Choice C), and bradycardia (Choice D) are unlikely findings in a client experiencing alcohol withdrawal. Stuporous level of consciousness is more indicative of acute brain dysfunction or coma. CT scan findings may indicate structural brain injury, such as a brain tumor or stroke. Bradycardia is not a common finding in alcohol withdrawal but may occur in severe cases. However, tachycardia is a more common finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
"Stay with the client during meals and for 1 hr afterward," and "Monitor the client's weight daily after first voiding." These are important interventions for clients with anorexia nervosa, as they can help to prevent complications such as dehydration and electrolyte imbalances.
Choice B, "Give the client a weight gain goal of 4 to 5 lb per week," is not an appropriate intervention, as it can be overwhelming and may promote unhealthy weight gain.
Choice D, "Encourage the client to keep a diary of daily food intake," may be helpful for some clients, but is not a priority intervention.
Choice E, "Offer specific privileges for sustained weight gain," is not an appropriate intervention.
Correct Answer is B
Explanation
Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.
Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.
Choice C, supporting the client's coping skills, is not a priority intervention.
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